William Wright, MD, a general practitioner at the Colorado State Penitentiary maximum-security prison, who wrote the book "Maximum Insecurity"

Expertise

Doug E. Woolley, MD: "It has certainly become apparent that generalized screening has not been nearly as useful as predicted. Are all screening professionals of equal capability? In my experience, in the first 10 years of practice I did digital prostate exams on all my low back pain patients and never detected a suspicious rectal or prostate mass so I gave up the exam. Was I incompetent as an examiner or were my patients all healthy?"

Earlexia Norwood, MD: "Very often cognitive screening is done not as a screening effort, but it's a diagnostic effort because of evidence of cognitive decline. There are signs noticed either by the patient, a family member, or co-worker. We do cognitive screening without signs or symptoms if patients have multiple health risk factors for dementia, family history of dementia, patients with advanced age, and based on patients' life expectancy and quality of life."

"Dementia is a disease of the elderly, and very often screening in this age population is done purely on age, but risk factors may put younger adults at risk for dementia due to ischemic and multi-infarct dementia. Patients with increased education are usually high functioning, and areas of the cognitive decline may only be noted with neuropsychometric testing."

William Wright, MD: "My personal criteria for any testing, whether a screening test or not, is whether the results will alter a subsequent course of action. I don't do tests just for curiosity unless they're part of a formal study. If there was a therapy that was clearly beneficial for cognitive impairment, I'd be much more sanguine about screening for it. Unfortunately, that's not the case."

Informed Decision

Nicole M. Leib, CPNP, MSN, RN: When interacting with a patient, it is important to explain what you will be doing and why you are doing it. This helps them to understand the purpose of certain questions and/or tests. Also, patients are privy to a large amount of information via the media and internet, for example; therefore, as a practitioner it is important to provide evidence-based information to help the patient understand the practitioner's recommendations and to make informed decisions.

Gwen Graddy-Dansby, MD: Including my patients in the discussion is an important part of getting a baseline. I begin by asking patients 'If there was something you could do to save your memory, would you want to do it?' Involving the patients at the beginning to know that this is done because their memories are who they are. If they lose their memory, they lose a part of themselves. This encourages patients to be actively involved in getting a baseline to look for potential decline in the future.

Kay Funk, MD: "The bigger obstacle is that many patients don't want to have their cognition 'screened' or judged. So requiring universal 'cognition screening' annoys the patient and drives a wedge between patient and physician. Why do that for no proven efficacy?"

Confounders

Woolley: "In my experience if a condition is chronic and stable then it tends to be ignored. We found by screening patients for problems such as cognitive status, anxiety/depression, diabetes/cardiac association, previous anesthetic problems, and drug interactions, multimodal symptom management protocols for pain/nausea/diabetes/sleep apnea, nocturia, mobility status and home support, etc. were all important, predictive factors that determined a "good result" and required attention to detail. A beautiful mosaic is made up of all the tiles, and leaving one out can destroy the effect."

Funk: "Cognition screening is an excellent example of how the 'top down' CMS mandates from Medicare don't work in the real world. Assessing cognitive impairment in a meaningful way is time consuming and doesn't really fit into the time limits of the CMS designed visits and compensation.

Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback issue, reach out to e.chu@medpagetoday.com or @elbertchu.

MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.

Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) and Continuing Education (CE) credits at no cost for participating in MedPage Today-hosted educational activities.